Child Psychiatry

Question 1

Review common diagnoses in pediatric mental health

Answer 1

Mood Disorders

Question 2

Recall first line treatment guidelines

Answer 2

Medications = SSRIs
Fluoxetine (Prozac)
Escitalopram (Lexapro)

treatement as well as behavioral or psychosocial interventions

Question 3

Major Depressive Disorder:

Answer 3

Persistent Depressive Disorder (dysthymia)
Bipolar Disorder
Disruptive Mood Dysregulation Disorder *
(Bipolar Disorder)

Question 4

TEST: 2 Exceptions with SIGECAPS:

Answer 4

you have to ask “are you down” or about Irritability, as this may be the predominant emotion that is displayed as opposed to “sad”

Question 5

epidemiology of mdd in kids and teens:

TEST: by the time you get out of high school, around _______ of kids have had at least 1 depressive episode

Answer 5

Point prevalence: 2% of children, 4-8% of adolescents
Lifetime prevalence by age 18yo: 10-20%- this DOESNT mean lifetime diagnosis, but it means we’re unerrecognizing and undertreating this

10-20%

Genetic Loading
40-60% heritable

Question 6

First line treatment for MDD:

Answer 6

Psychotherapy (cbt) or IPT (trying to be understanding that if your dad doesn’t show you effection, maybe that’s just him and you have to learn to accept that)

12-16 session with therapis, deep breathing, different things you can do when you’re down

then medication
SSRI
Fluoxetine down TO AGE 8
escitalopram down TO AGE 12
IF THE KID IS 9, YOU ONLY CAN USE FLUOXITINE!!
ONLY 2 APPROVED BY FDA FOR USE ON KIDS
NEVER PAROXATINE
TCA are shown not to be effective
NEVER MAO

Question 7

TEST: IF THE KID IS 9, and they come to a child psychiatrist with depression, YOU ONLY CAN USE:

Answer 7

Fluoxitine

Question 8

Children and teens diagnosed with Bipolar Disorder are most likely to meet criteria for which of these disorders in adulthood?

Bipolar Disorder type I
Bipolar Disorder type II
Schizophrenia
Generalized Anxiety Disorder

Answer 8

GAD

once diagnosed with BP, it’s a lifetime sentence and you will be looking at a life long diagnoses with heavy medication

Question 9

treatment for DMDD:

Answer 9

Stimulants to target impulsive components of disorder
SSRIs for irritability/anger as depression equivalent
Antipsychotics if warranted for aggression and emotion dysregulation symptoms

Question 10

first line treatment for bipolar

Answer 10

lithium 12+
atypical antipsychotics for 10+ as mood stabilizers

aripiprazole
risperidone
quetiapine

narrow spectrum of diagnosis means that <1% of prepubesent kids are diagnosed with bipolar

Question 11

Separation Anxiety

Answer 11

Epidemiology:
Prevalence: 4% in children, 1.5% in adolescents
Highly heritable: 73% concordance in twins
Risk factors: sudden attachment disruption, intrusive/overprotective parenting

Diagnosis: Developmentally inappropriate and excessive fear / anxiety about separation from attachment figures

Question 12

Separation Anxiety

Answer 12

Epidemiology:
Prevalence: 4% in children, 1.5% in adolescents
Highly heritable: 73% concordance in twins
Risk factors: sudden attachment disruption, intrusive/overprotective parenting

Diagnosis: Developmentally inappropriate and excessive fear about things that likely won’t happen “mommy’s going to die” “I might be kidnapped”, etc

“I have a stomach ache I can’t go to school today”

Question 13

selective mutism
epidemiology:
diagnosis:

Answer 13

0.03-1%
boys=girls=all ethnicities
high comorbidities with social anxiety disorder

failure to speak in social situations that have expectation for speaking

interferes with educational achievement or social function

duration is +1 months
not attributable to lack of knowing/comfort with language
not attributable to communication disorder or asd or psychosis

Question 14

social anxiety:

Answer 14

over emphasis on being evaluated by your peers

epidemiology:
2-7% 12 month prevalence (grossly underdiagnosed)
2:1 females maybe even higher in adolescents

diagnostic differences from adults:
anxiety must occur w/peers, not just adults
fear/anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking

anxiety in going to the bathroom, eating, waiting in line in public

Not always “I feel too nervous talking to people” so I’m going to hide in the corner (more behavioral)

Question 15

TEST: PTSD is measured using the:

PTSD presents:

Answer 15

ACE test for “toxic stress”
anything over a 1 is considerable; these are often the big secrets, and you have to build up to talking to them or their parents
TEST: even if you’re not seeing flash backs, and nightmares and rage attacks, you have to be aware that PTSD still causes significant problems for children

Question 16

TEST: A 5yo child witnessed his mother repeatedly beaten by her boyfriend. Mother’s boyfriend also yelled at him and threatened him regularly. Which of these is true about his PTSD symptoms?

He may not show distress when re-enacting violence through play
He will always wet the bed at night
He will never be violent toward others because he knows what it’s like to be afraid
He will need medication to reduce hyperarousal symptoms at bedtime

Answer 16

He may not show distress when re-enacting violence through play
(always and nevers should always be thrown out)

Question 17

TEST: PTSD presentation:

Answer 17

Separation of criteria for children under 6yo: may not show distress with intrusions, reenactments
Exposure to trauma not just through electronic media
Intrusive memories or dissociations (flashbacks) may be through repetitive play reenactments
Nightmares may be frightening without discernment of actual content/themes

Question 18

TEST: when talking about kids under 6 who have PTSD, when talking about them having nightmares, they:

Answer 18

may or may not be frightening, and they may have nothing at all to do with the actual content of themes of what they’ve been traumatized by

Question 19

TEST: treatment for anxiety disorders is to:

Answer 19

graduate exposure to the fear. The treatment is to FACE the fear, not learning ways to avoid the fear, bc if you avoid it , it gets scarrier.

Social anxiety is the same: 1st step: go to starbucks and sit around othe people;
for kids, it’s different, go up to one kid and say hi and walk away. Step 2, say “nice shirt” then walk away, etc

Question 20

TEST: CBT for Anxiety or PTSD is all about:

Answer 20

not FORGETTING the trauma, but to integrate that trauma into their own sense of self. This happened to me, it wasn’t ok, and when I think of it, I will not let it crush me

Question 21

TEST: the medicatino of choice for anxiety and everything else:

Answer 21

fluoxetine (prozac), sertraline (zoloft), NOT TCAs
NOTE: fluoxetine and sertraline are probably even better for anxiety than they are depression, but they were labeled antidepressents first

xanex, adavan, closapane, valium- worst possible thing you can do (great for short term or once a week , horrible long term- never used with kids, period

Question 22

OCD:
epidemiology:

why?

First line?

Answer 22

1-2%, males earlier age, 25% by age 10yo
when appearing in childhood, it’s much more likely that there is a genetic component, but nothing identified (polygenic)

CBT, SSRI
only time TCA are possibly helpful

Question 23

Oppositional Defiant Disorder:

Answer 23

dennis the menace
temper, 
angry
argues, 
refuses to comply

Question 24

Conduct disorder:

Only treatment:

Answer 24

fights, uses weapons, physically cruel, steals, deliberately destroys peoples’ property, runs away, truant from school

not “I’m an annoying brat” I’m actually beating people, etc: (just a spectrum of severity- oppositional defiant disorder is kind of bad, conduct disorder is worse)

Try to teach parent to set stricter limits and enforce them!

Question 25

TEST: 2003, there was a black box label put on ssris in teens because:

Therefore, the number of prescriptions went____ and :

Answer 25

there was a 2x increase in suicidal ideation in 1 study. Went from 2%-4%, and it was NOT an increase in actual suicide, or anything else, only an increase in thoughts

prescriptions went down and the suicide rate INCREASED!

Question 26

TEST: regarding medication for child psychiatry:

Answer 26

children are often UNDER dosed (need to go lower or higher)

Question 27

TEST: _____ is the ssri contraindicated for kids

Answer 27

paroxatine